https://leader.pubs.asha.org/article.aspx?articleid=2280132Service Delivery in Schools: A National SurveyA survey finds that 30-minute speech-language sessions once or twice a week remain the norm.2012-01-01T00:00:00School MattersJayne Brandel, PhD, CCC-SLP

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School Matters | January 01, 2012

Service Delivery in Schools: A National SurveyA survey finds that 30-minute speech-language sessions once or twice a week remain the norm.

Jayne Brandel, PhD, CCC-SLP, is an assistant professor in the Department of Communication Disorders at Fort Hays State University. Her research interests include the assessment and intervention of language disorders as well as the efficacy of interventions for students within the school setting. Contact her at jmbrandel@fhsu.edu.

Jayne Brandel, PhD, CCC-SLP, is an assistant professor in the Department of Communication Disorders at Fort Hays State University. Her research interests include the assessment and intervention of language disorders as well as the efficacy of interventions for students within the school setting. Contact her at jmbrandel@fhsu.edu.×

Diane Frome Loeb, PhD, CCC-SLP, is an associate professor in the Department of Speech-Language-Hearing: Sciences and Disorders at the University of Kansas and Director of the Language Development Disorders and Intervention Studies Laboratory and the Multicultural Communication Disorders Laboratory. She is Coordinator of the NTrainer NICU Follow-Up Clinic. Her research interests include language development and disorders and intervention efficacy in children. Contact her at dianelo@ku.edu.

Diane Frome Loeb, PhD, CCC-SLP, is an associate professor in the Department of Speech-Language-Hearing: Sciences and Disorders at the University of Kansas and Director of the Language Development Disorders and Intervention Studies Laboratory and the Multicultural Communication Disorders Laboratory. She is Coordinator of the NTrainer NICU Follow-Up Clinic. Her research interests include language development and disorders and intervention efficacy in children. Contact her at dianelo@ku.edu.×

Most school-based speech-language pathologists use traditional service methods—group treatment once or twice a week for 30 minutes—for most of their students, despite the availability of alternative methods and their belief that they individualize treatment.

This seeming discrepancy, revealed from a survey of school-based speech-language pathologists, may be the result of several factors, including the clinician’s caseload size and graduate training (Brandel & Loeb, 2011).

The knowledge base for school-based speech-language services as has grown immensely as a result of research, scientific advances, and clinical insight. But according to the survey, fielded to determine how those gains have kept pace with policy and translated into modifications in service delivery, not much has changed since 1910, when school services first were provided. Early speech-language treatment was provided in 30-minute group sessions outside of the classroom two or three times each week (see Duchan, 2010 for a review). The survey also validates findings of previous studies (ASHA, 2008; Mullen & Schooling, 2010).

Given these findings, are students’ needs driving treatment decisions, as required by the Individuals with Disabilities Education Act (IDEA) reauthorization (2004)? IDEA provisions call for school teams to individualize services for students, including service delivery decisions.

Service Delivery Options

Throughout the past 100 years, a variety of service delivery options have been proposed to accommodate the needs of students and SLPs. Three broad categories of service delivery are detailed in the accompanying chart [PDF] (Case-Smith & Holland, 2009):

Direct services are delivered by an SLP within or outside the student’s classroom, individually or in groups.

In the consultative model, the SLP provides suggestions and training to improve participation and learning within the classroom.

Flexible service delivery combines direct and consultative services, depending on the needs of the student at a particular time.

Research is a crucial aspect to our accountability as a profession. Unfortunately, there is little research to guide school-based SLPs in determining how often, where, and what type of service-delivery model should be used when making recommendations to the student intervention team (Warren, Fey, & Yoder, 2007). The systematic review by Cirrin et al. (2010) demonstrated that services provided within the classroom result in changes similar to those provided outside the classroom. However, even these findings require careful replication and validation.

We are beginning to learn the importance of intensity from Head Start preschool classrooms. Moyle and Berman (2011) reported that higher intensities are more effective than lower intensities for preschoolers’ vocabulary and oral-language learning. However, the same is not necessarily true for print awareness (McGinty, Breit-Smith, Fan, Justice, & Kaderavek, 2011). McGinty et al. (2011) identify two aspects of intensity (dose and dose frequency) that interact with each other and need to be taken into consideration when determining intervention intensity.

Survey

The online survey was administered from October to December 2008 using SurveyMonkey. SLPs were asked to report the intensity of services delivered and the service delivery models used for students at varying grade levels with mild, moderate and severe disabilities (see Table 2 [PDF]), including articulation, pervasive developmental disorder, pragmatics, learning disability, intellectual disability, alternative and augmentative communication use, specific language impairment, and reading/writing. Their responses were evaluated to determine if any factors (e.g., caseload size, year of graduation, graduate training experience) were associated with their service-delivery choices.

The questionnaire was completed by 1,897 SLPs from all 50 states and Washington, D.C. Their average caseload size was 51. The respondents had worked in schools from one to 42 years, with an average of 15 years. SLPs most often reported that in graduate school, their school-based clinical training involved treating students outside of the classroom individually and in groups.

Results

SLPs were asked to identify the top three factors that influenced their treatment recommendations for program intensity and service delivery model. For both of these issues, respondents indicated that the most important factors were the nature and severity of the student’s disorder; the student’s communication needs as related to his/her general education curriculum; and the student’s strengths, needs, and emerging abilities.

However, when SLPs were asked to report the intensity and service delivery models they were using with students of varying disabilities and grade levels on their caseloads, they reported limited variation:

Students with moderate and severe disabilities most often participated in services two or three times a week for 20–30 minutes.

Students with the least severe disabilities participated once a week for 20–30 minutes.

Regardless of the severity or age, students most often participated in intervention in groups outside the classroom (Brandel & Loeb, 2011).

Based on the survey responses, factors such as caseload size, year of graduation, and graduate school clinical training experiences were evaluated for their effect on service delivery. Caseload size was the most consistent factor affecting intensity of services and service delivery model selected. Clinical training experiences during graduate school training were found to influence service delivery as well.

Lack of Variation

The survey results raise a significant question: Why do SLPs overwhelmingly provide services to students once or twice a week for 20 to 30 minutes in groups? Is this schedule intense enough to result in significant gains? Unfortunately, little research evidence can assist in answering this question. There is evidence that language intervention can result in significant gains. Gillam et al. (2008) found significant gains in language skills when intervention was provided every weekday for six weeks for an 100 minutes each day. This approach is similar to block scheduling in that intervention was provided for a short, intense period (six weeks) followed by a similar period of no intervention. Yet, only 2% of SLPs completing the survey reported ever using block scheduling.

Why is intervention overwhelmingly provided in groups regardless of severity, disability type, or grade? SLPs in survey follow-up e-mails indicated the results were most likely because of scheduling and caseloads. Yet, the results of the survey found only caseload size to be a significant factor. Specifically, our results found that students are less likely to participate in interventions in varying service delivery models or intensities when SLPs have large caseloads. This finding suggests that caseload size is affecting SLPs’ ability to provide individualized services as mandated by IDEA (2004).

Implications

It appears that although SLPs believe they are making recommendations based on student characteristics, it is possible that other variables such as graduate training, caseload size, and teacher schedule are affecting decision recommendations. It may be worthwhile for school-based SLPs to track the factors that influence intensity, place, and type (group/individual), and to evaluate these factors to detect a possible pattern. As service providers for children with disabilities, we need to evaluate current practice to determine if we have unknowingly become routinized in our recommendations. Student teams rely on our recommendations for service delivery model and intensity. Self-evaluation of recommendations is important to ensure that these recommendations remain student-centered despite other, outside factors.

Graduate training programs have the opportunity to lead the way in helping SLPs to avoid routine recommendations in two important ways. First, graduate students need the opportunity to practice making individualized decisions regarding service delivery (both the approach and intensity) under the guidance of certified and licensed SLPs in their clinical training programs. This goal could be accomplished with different levels of support throughout the graduate program and need not be left to a field site or externship experience. Given that the survey indicated that SLPs overwhelmingly are trained to provide individual and group intervention outside the classroom, it is not surprising that services are being provided in this model. A wider variety of graduate school service delivery experiences could help clinicians identify students who might benefit from a different service delivery model. If this training is not possible, explicit discussions regarding the decision-making process could be used to guide graduate students who, in practice and intent, may therefore be more likely to maintain a student-centered focus to their intervention decisions.

Secondly, graduate training programs could conduct research on current service delivery practices. SLPs in the schools would benefit from data regarding the effectiveness of speech and language intervention being provided in schools. In addition, information on what intensity and/or service delivery models are most effective for students at various grade levels and disabilities could provide SLPs with objective information on which to base their recommendations. Our hope is that such studies eventually will pave the way for service delivery recommendations that are optimally individualized and evidence-based.

Looking Ahead

School-based SLPs need and deserve research to guide their decision-making. For a number of students, intensity, place, and type of services are the same as in 1910. This finding is not surprising, given that the majority of SLPs report itinerant experiences as their primary experiences during graduate-school training. But research is needed to address several important questions:

What are other reasons that the pull-out group model is used so commonly in the schools?

Do some goals require more intensity than others?

What are the reasons to conduct individual versus group intervention?

How effective is block scheduling? Is it more effective only with certain types of goals? Can it realistically be used in schools?

How effective is the consultation model with various levels of severity, goals, and disability types?

What factors effect group membership success (i.e., how do I form successful groups)?

Why are clinicians not using classroom-based intervention more frequently?

Can students make similar gains with others providing the intervention (e.g., paraprofessionals, classroom teachers)?

Studies that address these issues will begin the research track needed for SLPs serving preschool, elementary, and secondary students with communication disorders. Such studies will allow school-based SLPs to make informed, research-based recommendations.